Cosmeceuticals Applied to Skin during Microneedling. Safety, Efficacy, and Restoration of Sanity. | BareFacedTruth.com

Cosmeceuticals Applied to Skin during Microneedling. Safety, Efficacy, and Restoration of Sanity.

Primum non Nocere. First, do no Harm. It is a guiding principle in medicine, although in the world of skin care and topical aesthetic medicine, we seem to have been lulled into a sense of complacency at times. It is rare to see complications of topically applied solutions, and when we do they are usually non-fatal and self-limiting. Which is due to the fact that the skin itself is well designed as a protective barrier. Most of what we slather on never gets past the top few layers of cells,, which is why so many technologies have been invented to try and overcome that amazing ability to reject foreign substances. But skin is, in fact, vulnerable when we ignore certain basic physiologic imperatives. Even intact skin can be an entry portal to a few molecules of a substance applied to it.

What happens next? A chemical applied to skin may be ignored, or perceived as benign or even “friend, not foe”. Alternatively, a substance may be identified as a dangerous foreign invader, resulting in an emergency response system designed to fend off potential damage. This is how our skin protects us against harmful agents of all sorts, be they chemical or biological. The warning signals are transmitted by communicating molecules (cytokines) in a mechanism called paracrine (cell-to-cell) and autocrine (amplified within cells) signaling. These signals cause cells of the immune system to be mobilized to the site of penetration, setting up an inflammatory reaction whose purpose is to wall off or destroy the invader, thereby restoring the skin’s integrity whenever it is breached.

Chemical friends, chemical foes

Nearly anything that the body does not recognize as its own (e.g. things that are not “physiologic” to humans – chemicals that humans don’t themselves make) or as a friendly is subject to being identified as an enemy alien when applied to skin.

Different parts of the immune system get involved depending on the nature of the invader. Biologic pathogens get special attention. Toxins are obvious – these are substances most people will react to. Like poison ivy. Then there are things that some people respond to because they are “allergic” to them. That is partly based on genetics, but other factors play a role.   Pollens of various sorts are an example. Some people are allergic when they breathe these in, causing hay fever and other respiratory problems. Foods can also cause allergies. Allergic reactions to chemicals in foods and in the air can be fatal. Skin also can be a portal to such dramatic emergency responses. A very dramatic example involving skin is bee venom allergy. All it takes in a single small prick into the superficial dermis of susceptible (allergic) individuals, depositing a tiny amount of a toxic chemical, for this to trigger a potentially deadly systemic (total body) reaction called anaphylaxis.

 

Skin testing procedure in common practice

The most common form of allergy testing in a physician’s office is called prick or puncture testing. A diluted drop of a test substance is placed on the skin and then that skin pricked with a very small needle. The tested area of the skin is observed for about 15 minutes to see if a reaction develops. The “wheal”—a raised, red, itchy bump and surrounding “flare”—indicates the presence of the allergy antibody when the person is exposed to specific allergens. The larger the wheal and flare, the greater the sensitivity.

Although skin testing may seem simple, it must be carried out by trained practitioners with an understanding of the variables and risks of the testing procedure. Often multiple substances are tested simultaneously on a patient’s back or arm.

Microneedling mimics the allergist’s “skin test”

This classical paradigm for skin testing is mimicked when microneedling is performed in the presence of a substance applied to skin before, during, or soon after needling. Both cosmetic or medical needling accomplish this. The applied substance will gain access to areas beyond the skin’s natural protective surface. After needling, the protective barrier is no longer intact, and the skin is vulnerable to whatever it comes into contact with for several hours until the microneedling channels have formed effective “plugs” (early phase of the healing cascade) to restore skin barrier defenses.

inflamed skin

Acute and chronic inflammation

We have been describing sudden onset or “acute” types of reactions involving the immune system and skin’s defensive mechanisms. But not all inflammatory events are immediate – some are slower in onset and present in more occult or insidious manner. We might term that a “subacute” response, distinguishable by the types of immune cells involved, and their behavior. A granuloma is one type of subacute immune inflammatory response that tends to develop over weeks or even months, gradually becoming apparent as a focal or localized lesion. These are discussed in more detail below.

Perhaps the most common skin reaction to irritants is one best described as chronic and insidious. We sometimes call this “subclinical” inflammation, as it may not cause surface signs of redness and swelling. But, below the surface, inflammation is taking its toll on matrix proteins and structural cells of the dermis. It is what we call “skinflamm’aging”, as it resembles skin changes associated with aging itself. Indeed, it is accelerating that process (rather than slowing it down). Even trickier, there may be a temporary masking of the signs of aging on the surface (swelling from inflammation can distort skin and reduce the appearance of wrinkles).

Chronic forms of inflammation are less likely to be associated with a single or minimal exposure to an offending chemical (e.g. with microneedling) than with daily application of a toxin. But it is not uncommon to see people using the same cosmeceutical both during microneedling. In this case we might consider the microneedling exposure to be a “sensitizing” dose which sets the skin up for stronger immune responses to the same chemicals applied chronically.

granulomatous inflammation

Microneedling complications

Our close colleague and occasional BFT blogger, Dr. Lance Setterfield, M.D. (DrLance), spends the majority of his time traveling the globe giving master’s courses and seminars in techniques of microneedling. He has written the definitive book on the subject. Since the publication of the first edition of his book, there has been published a case series documenting the problem of granulomas developing after facial microneedling.

A granuloma is a type of inflammatory process where the immune system tries to wall off to substances that it perceives as foreign but is unable to eliminate. A granuloma can form in response to organic or inorganic material, microorganisms, chemicals, etc. Granulomas can be infectious or sterile. They can undergo necrosis. They can inflame and distort nearby tissues.

In addition to granulomas, needled skin can show a variety of other “pathologic” responses to foreign substances. Allergic responses, or hypersensitivity reactions, as we have described above, is one. Irritant contact dermatitis is another. These are generally more serious when substances are applied to recently needled rather than intact skin. The signs can be swelling, redness, pain, and even loss of function (e.g. speech and eating disturbances, visual distortions, breathing difficulties).

Such reactions can be difficult to detect at first, because a certain amount of hyperemia (redness) and swelling is common following medical needling. Microneedling by its very design causes a measured degree of damage resulting in inflammation. Indeed, it is the normal, physiologic response to that damage that brings with it the desired aesthetic result. Usually things calm down within hours or a few days, depending on the needling depth and other treatment parameters including skin characteristics of the patient.   If they do not follow the expected course, something more insidious (and pathological) may be at work.

It goes without saying that all patients need to be fully informed of the potential complications before such procedures, and that they sign an informed consent. This protects both patient and clinician in the event of an adverse result.

What NOT to apply during microneedling

Here we get to the crux of the matter. We have debated this extensively, and it has been the subject of considerable discussion amongst those who spend a good deal of time working with microneedling, and who have contributed to the evidence base.

DrLance likes to call these offending substances “troublemakers”. In the first edition of his book he has a whole section devoted to these. With his experience since that book was published, and as clinicians worldwide have shared their experiences, the paradigm has shifted somewhat. It seems that there are a lot of troublemakers, and it might be a much shorter list to identify those that are not than those that are, in practice or in theory.

A conservative approach to microneedling adjuncts would be to only apply substances which are:

  1. Physiologic to the human body (in other words, humans make those same molecules as part of their genetic machinery or metabolic processes, and 
  2. Do not pose problems in theory or practice based on their nature, function, or origin, and
  3. Helpful in that they offer something good, not just absence of something bad

The first two safety concepts overlap, but not completely. Clearly, not everything that is physiologic is desirable, for other reasons, e.g. due to its origin or other factors. For instance, hyaluronic acid is physiologic (made by humans abundantly). High molecular weight HA is trophic to skin, but low molecular weight fragments can have the opposite effect. Thus, although HA is generally biochemically a good thing (hydration, pen glide, potential sealant) you want to be careful of its source or origin (some companies sell LMW or MMW HA which can be catabolic).

facial hypersensitivity response

Dr. Setterfield’s recent example

The controversy that erupted on Dr. Setterfield’s blog provides an interesting example. One commenter kept touting the use of a cosmeceutical during needling that contains (amongst other things) the mucous of snails. This controversy persists, even after DrLance revealed his personal experience in observing a severe problem arising when a snail mucous product was used during microneedling.

What is this stuff anyway? Well, it seems that is in not just any mucous, but the defensive mucous produced when a snail is under threat (e.g. poke it with a stick). The abused snail in question goes by several names, as mollusk biologists cannot seem to agree on the proper taxonomy. Cryptomphalus asperses, Cornu aspersum,  Cryptomphalus asperses, Helix aspersa all seem to refer to the same critter, a common garden snail.

Now, we at BFT wrote about snail snot and fairy dust some time ago as it proved to be the perfect tongue-in-cheek target for our discussions of the epistemology of skin care (theory of knowledge) which we find important because there are so many things we find worthy of ridicule, (as regular BFT readers know). Now, we have updated our research on the snail snot phenomenon, and will update you quite soon with Snail Snot II. It is actually an interesting story, complete with a genesis tale of “accidental discovery” (you know how we love those) in distant, non-English speaking lands (it is a national shame that the U.S. is so far behind in cosmeceutical biochemistry. Why is that??). A subplot is the drama of patents (follow the money), who makes & sells it (some real conundrums) and the latest research (interesting, maybe even surprising).

But we digress. Today we skip over all the potential benefits of snail snot and point out the glaringly obvious (you have already guessed it if you have read this far). This is a really bad idea as an adjunct to microneedling for reasons of safety (real and theoretical).

Xeno chemicals are high-likelihood troublemakers

We find it truly remarkable that well-meaning folks are poking your skin with needles after applying a mixture of xeno (foreign, animal, not human) proteins and other chemicals. This is not rocket science, folks. Look at the common allergens tested in a typical allergy test in the doctor’s office. Feathers. Cat dander. Sheep wool. All animal derived. This is an allergy test gone wild! A total face allergy test.

So, we looked up the research that would tell us what was in this concoction. Not surprisingly, extremely little is known. Snails don’t have their own NIH division to sponsor solid biochemistry research into mollusk slime.

This publication documented several functional assays, such as human fibroblast proliferation, to try to make the case that the cocktail of snail biochemicals acted as a growth factor for skin. And yes, behold, a very weak effect on human fibroblast survival and proliferation. What the researchers failed to mention is that you can add just about anything to a culture of fibroblasts and see the same thing. Proliferation in dermal fibroblasts is something of a stress response in itself. As I like to say, you can simply spit into your fibroblast culture and make them pump out more ECM materials. Of course, when you look at the cytokine content of human spit/snot, not to mention the defensins (host defense peptides) etc., you can see that it (just like gastric slime) has remarkable stress resisting or defensive properties itself.  

a trail of growth factors?

Snail “growth factors”. Ahem.

Now, here’s the kicker. The authors of this work went on to postulate that snail snot contains a growth factor, and speculate that it is just like human bFGF (basic fibroblast growth factor). The problem is (as they state it) there is no assay for snail bFGF. If it even exists. I would point out a bigger problem: there is no evidence that snails make anything of the sort. The lower on the phylogenetic scale, the smaller the array of cytokines and growth factors, and they are highly species specific. We know a lot about the drosophila genome, and those guys (fruit flies) have a very limited repertoire. Even our not-so-distant mammalian cousins (e.g. mice) make different versions of growth factors, and these do not fit the human receptors for same. So, even if snails make a growth factor (let’s call it SGF) how does this growth message get transmitted to human fibroblasts without a SGF receptor? Or are they also speculating that humans have AGF receptors? By what logic do we validate that speculation?

This “growth factor” story is troublesome. The publication that makes this claim stretches credulity, is marred by internal inconsistencies, and just fails to impress as serious research. Because human cells have no receptors for snail GF’s that may or may not exist, there cannot be paracrine cell-to-cell communication of a trophic message between human keratinocytes as there is for human cytokines and GF’s. The paracrine (and autocrine amplification) of these chemicals is part of why they have a distinct advantage, and why human GF-based products can work even with minimal penetration or nanogram doses. This is the beauty of receptor biochemistry. The equally valid speculation that follows is that if there was an effect of some snail snot chemical in churning fibroblasts it might well be due to a stress response, not a coordinated physiologic response. After all, these is stressed snail snot, right? So a stress chemical (conserved from mollusks to humans) is a far more likely hypothesis than a conserved “growth factor”.

This is not mere species confusion, it is also market obfuscation. Trying to capitalize on real human biochemistry advances by using the same word (growth factor) when it contains nothing of the power or biochemical elegance conferred by the real thing. This reminds BFT of the whole plant stem cell farce. Plant stem cells have little in common biochemically with human stem cells. Using the stem cell phrase/meme association bastardizes the real science, and confuses people. Not nice. Not truthful.

Does it even do anything good?

Having dealt with the safety side of the picture, discussing what should not be applied to skin during microneedling, we are left with the equally germane notion, that being “does it help?”. Since microneedling has a known biochemical effect of it’s own, why bother to add anything to the picture? What sort of things might actually improve the dermal regenerative response to microneedling

Let us first dispense with mechanics. Microneedling with a pen is made easier if friction between the device and the skin is reduced. This is typically referred to as “glide”. There are a number of chemicals that could provide glide. The most commonly used is hyaluronate (HA). It is physiologic to humans, and has the advantage of also being ostensibly the most researched facial filler on the planet. Not to say that it has a perfect safety record (it doesn’t) but perfection is the enemy of good, and we are not aware of reports of microneedling related adverse reactions to HA alone. So, it is safe (as long as it is the high molecular weight version), and effective for glide, and barrier restoration (at least in theory).

Beyond mechanics, what about some positive effects form a biochemical approach? What would you want? Logic dictates we would want something that would amplify or compliment the known mechanism of action of the microneedling itself. Not something that would get in the way.

healing phases

Microneedling microtrauma and healing

Microneedling induces minor, controlled damage to skin and sets in motion a predictable healing cascade. The well-characterized sequential phases of healing begins with hemostasis and ends with restoration though tissue regeneration. Given time, and with repetition, your body’s natural regenerative processes will fashion a final result that is aesthetically desirable. The extent of that change, however, is limited by variables such as an individuals age, health, skin type, and a host of other matters. Our regenerative capabilities, like so many others it seems, begin to decline from the moment we are conceived. The clock is constantly ticking.

True regenerative ability actually peaks at about 16 weeks gestation – fetuses have a remarkable ability to heal in a way that is without any fibrosis. Fibrosis, to oversimplify matters, is healing that is marred by scarring or poor quality cross linking of matrix proteins (collagen & elastin). By the time we are 50, we have lost about 95% of the regenerative capacity we had as fetuses. The older we get, the more prone we are to fibrotic healing. Hence, the signs of aging, skin and internal organs alike. This largely has to do with senescence and a loss of the type of stem cells associated with rescue and regeneration.

Now, before we go any further down this path, let us remind you that we (DrGeorge and DrJohn) are stem cell research docs. We are all about cytokines & growth factors (which are the key products of a certain class of human stem cells known to be at the very core of our human regenerative capacity). As such, we have our biases (and we remind you about them all the time), idiosyncrasies (science curmudgeons), and pet peeves. In fact, we just reminded you of one of our pet peeves (calling things from plants & snails growth factors so as to capitalize on human growth factor research without ever having done any). We will try to avoid talking about our own products, as this is a noncommercial science & beauty blog. But we readily acknowledge that our opinions are influenced by our own work. There you have it, our usual disclaimer.

What can we borrow from natural human healing & regeneration?

OK, so how would one go about improving on microneedling (without bringing in “troublemakers”, as DrLance likes to call them)? I suppose you could invent a pharmaceutical substance that replicates or accelerates what microneedling does. Or, you can take a page from nature, examine precisely what microneedling does, how it does it, and fill in the gaps. Here is one gap: older people (like me) don’t mount the same cytokine & growth factor response as young people do. The older I get, the worse I perform. The older I get, the more prone I am to healing by fibrosis. The older I get, the more prone I am to releasing inflammatory cytokines, which can flip the switch from anabolic (volume restoring) to catabolic (tissue dissolving) growth factor profiles. So, how about supplementing my microneedling induced GF&C profile with something to push it towards that youthful (even fetal) GF&C profile? That makes sense. Good physiology, logical, and with no troublemakers.

The further advantage of using human biochemicals (in fact they are “natural” in the purest sense of the word, my fellow humans) has to do with the issue mentioned above of penetration or absorption. Growth factors (including snail ones, if they actually have any) tend to be large molecules. Very little penetration. In wounds, chance of get eaten up quickly by proteases. Not so with human biochemicals. The message molecules attaches to a cell receptor, and that cell makes more of the same chemical, and excretes it between cells to signal the cells nearby (deeper) and so forth. A cascade, with built in amplification. Not so with pharmaceuticals unless designed to attach to the same receptors. In which case they are termed analogs to growth factors and cytokines. To which we say, “why bother”, when human specialized stem cells abundantly make the real thing and in just the right ratios, along with a bunch of other relevant factors). And if we don’t want to use the ones they make, we can make our own by employing recombinant technologies informed by stem cell bioinformatics. Truly “bioequivalent”, in fact, bio-identical molecules.

Growth factors in isolation

Mind you, to be fair, growth factors applied willy nilly, without giving thought to the bigger picture, can transform them into troublemakers. Single growth factors (we have written here extensively about EGF applied alone) can distort the process of tissue regeneration. Nature doesn’t apply single growth factors to a problem. They come in complex arrays (cocktails) perfectly balanced for coordinated regeneration.

This post is way over word budget. Lets open this to comments & questions.

 

128 Comments

  1. Victoria Ammoscato says:

    I enjoyed reading this very much, apart from the fact that it contains essential information in addition it is very well written. Thank you for the serious facts but delivered so well and for making me smile.

  2. jom says:

    Hi Dr J, can you provide a link or citation to this study you referred to – “published a case series documenting the problem of granulomas developing after facial microneedling.” Also, what is your opinion of Dr Fernandes’ aggressive post-needling protocol of using Vitamins A & C and AHA’s? And, you never really answered your own question of what ingredients are best to use post-needling. Are you saying HA is the only good choice? Thanks

    • drjohn says:

      Hi jom, here is a link to the paper in JAMA Dermatology: Facial Allergic Granulomatous Reaction and Systemic Hypersensitivity Associated With Microneedle Therapy for Skin Rejuvenation . As to Dr Fernandes’protocol, I would point out that this approach was developed early on, well before there was a the huge volume of clinical experience that has been accumulated in the past several years. And, if you note in the journal article, two of the patients had undergone “microinjection” of a Vitamin C serum”. But of course that serum contains a lot of other stuff, as serums tend to do. Vit. C (at least in low doses) is physiologic. But, then again, the molecular form you find in a particular serum may not be all that natural (e.g. ascorbyl tetraisopalmitate). So, lots of things to consider in terms of causation. In this post, we tried to define criteria for designing a microneedling adjunct rather than limit discussion to one particular biochemistry. Several strategies would fit the criteria. Our own work focuses on growth factors and cytokines, and in our own research clinic we use a product we created specifically for microneedling containing (only) high molecular weight HA and a defined mix of (human) GF’s & cytokines. All physiologic, all natural stuff. The good it does is to shift very rapidly from inflammatory to non-inflammatory healing thereby leading away from fibrosis, and favoring well architected (basket weave) collagen. A number of clinicians are using this now and reporting excellent results. We are studying it more formally under protocol, and will publish results in the future.

  3. jom says:

    Thanks DrJ, I look forward to your research results!

  4. jom says:

    Another question – is your post-needling product for sale? How would one go about buying it? thanks

    • drjohn says:

      It’s only available through physicians and some estheticians. It is not a post-needling product but rather an intra-needling (before-during-right after) product. Between 2-12 hours after needling, the skin barrier has recovered to the point where the barrier has functionally returned to normal. In our protocols the patient uses AnteAGE MD twice daily once the critical period of vulnerability has lapsed.

  5. Robert says:

    I’ve been rolling very consistently for over 3 years now. Most of that time following Dr. Fernandez’s protocol. I have a question that I can’t seem to find the answer to no matter how hard I look or what forum I go to. How often does Dr. Setterfield recommend rolling with a 0.5mm roller? On his site Dermalintegrity.com they say to you can roll the face once every week but I’ve read statements from him on other links saying once every 28 days. Without having to buy his expensive book or take his course, what is the correct answer? Thanks

    • drjohn says:

      Robert, I will make sure that DrLance answers for himself upon his return from Europe in a few weeks. Meanwhile I will give you my take, which is largely informed by spending a lot of time with DrLance discussing these issues. Medical needling (0.5 mm or more) should be infrequent, spaced at least 2-4 weeks apart to allow healing around the dermal-epidermal junction, and to prevent scar tissue formation and collagen bundling problems due to due to chronic stimulation of the first phase of healing which is inflammatory. Cosmetic needling (0.2-0.3 mm) does not penetrate beyond the epidermis, and can be performed more frequently. Even daily, according to DrLance, although that might seem a tad obsessive. I might tend to argue that point with him and insist on a few off days between. The key point is that with cosmetic needling the keratinocytes can rapidly regenerate and the healing cascade or cytokines & growth factors can reboot much swiftly when needling trauma is limited to the stratum corneum (uppermost) layer of the skin.

  6. Clelia says:

    Vampire Face Lifts come to mind when I hear about stem cells being injected into the face. Here the stem cells are taken from the person undergoing the procedure. There is much controversy about this as some say it may cause cause growth in cancer cells. I also wonder if the serums you are creating would be customized with the person’s own cells or cells from other sources. Wouldn’t there be more chances of an allergic reaction if the stem cells come from other sources? There is a lot to think about here. I came across this article, which delves into it a bit.
    http://www.scientificamerican.com/article/stem-cell-cosmetics/

    • drjohn says:

      Clelia, you bring up some great questions.

      First let me correct you in that we are NOT talking about injecting stem cells int the face, or anywhere else. Your cells, or anyone else’s. Our platform utilizes stem cells as a smart factory to make growth factors and cytokines, and we can control the final mix of biochemicals in the cocktail. It’s a whole different thing than injecting cells. Cells contain DNA & all sorts of stuff we are not wanting. Cells have surface markers than can be recognized as “foreign”, necessitating harvesting your own cells to prevent allergic type problems (as in vampire facials). Stem cells when injected can be influenced by chemicals to differentiate into e.g. bone cells. We don’t inject cells. It’s not the cells we want, but rather we are seeking 1. their intelligence, and 2. their ability to synthesize the chemicals associated with regeneration so that we can replicate a youthful, non-fibrotic, non-scarring, aesthetically desirable healing environment. And it’s all natural. Your body makes the same chemicals. Now the cells are very special – their whole job in human physiology is repair and regeneration. But most of their work is accomplished through these communicating biochemicals.

      One way to explain the difference between cellular and biochemical therapy is by considering diabetes. You can transplant pancreatic beta cells (insulin producing cells) or even implant stem cells trained to produce insulin (human trials of this were just started). That is cell therapy. Or, you could employ cells that make insulin in the laboratory to create an insulin factory, then inject that insulin to treat diabetes (which is done every day by diabetics around the globe). No worry about allergy if the insulin is true human insulin, identical to what your own body makes, but in diabetes is not making enough. In the old days we used pork insulin, slightly different compared to human insulin at the molecular level, and guess what? Some people become immune intolerant (allergic), either acutely, or chronically. That points again to the xeno problem we identified in this post. (I wonder if snails make insulin?) Obviously injecting pure isolated insulin is not as complicated or scary as injecting or implanting cells and tissues, which is the point we are trying to make. Also obvious, as with insulin, you need to supply these chemicals daily, not just a one time deal.

      The article you mention was actually pretty good, but missed the mark in failing to make the distinction clearly when discussing “stem cell creams”. We will address this and other publications more fully, as well as address a number of misconceptions out there on the internet, in part 2 of Stem Cells and Growth Factors in Skin Care. Hype v. Hope which will be posted in the next few days.

  7. Drgeorge says:

    Clelia, the Vampire Facelift, actually a marketing trademark registered by an enterprising physician, does not involve the injection of stem cells at all. By definition, it is the injection of autologous PRP, which means the patient’s blood is drawn and centrifuged at high speed to isolate the platelet rich plasma (PRP). The platelets are activated using calcium, causing them to degranulate, a fancy way of saying expel the contents contained within the alpha granules within the platelets. So, in fact, what is injected are the cytokines and growth factors found within platelets, which exist in a highly inflammatory pattern.

    It was discovered in the 1990’s that platelet derived growth factors aided in the healing of chronic diabetic ulcers, and now it is also used to help repair bone defects, and tendon injuries. PRP is therefore a valuable adjunct to use when it is desirable to initiate inflammation in the hopes of stimulating improved blood flow and cellular proliferative activity. But, it does have a downside.

    Consider that platelets are the first cellular components to be called to task in an injury, to help stem blood loss and leakage. They are very good at this, and throughout human history, a robust inflammatory initial phase of healing has served a noble purpose i.e. destroy pathological microbes and help remove devitalized tissue. But, consider that a dog bite and a sterile surgical incision are both subject to an inflammatory phase – very helpful in the dog bite, not truly necessary with the surgical incision. So our healing cascade can be a two-edged sword.

    You mentioned the Vampire Facelift, where PRP is injected. There is also the Vampire Facial, where PRP is applied to the skin during a microneedling session. What is the value in that? We’re not convinced that acute inflammation is a desirable phenomenon to deliberately trigger since it is preferable that inflammation not be too robust or linger too long. Dr. Setterfield describes in his book and teaches that inflammation is best avoided, or quenched as soon as possible. The intention is to produce a healing phenomenon, but one that avoids prolonged inflammation so that chances for pigmentation and fibrosis are minimized. When you consider that microneedling is a procedure that is most often done in a series of multiple treatments, deliberately instigating a robust inflammatory response with PRP seems counterproductive.

    Drjohn has described how we use cytokines and growth factors derived from laboratory culture of bone marrow mesenchymal stem cells as a topical used in conjunction with microneedling. To us, this seems a preferable and well reasoned approach because of the strongly anti-inflammatory pattern these cell produce, the “command and control” role they play in tissue healing throughout the body, and the fact that with age our endogenous population of these important cells dwindles dramatically. Because it is the bio-signals that these cells produce that promote reduced inflammation and non-fibrotic healing in our skin and elsewhere, it is only necessary to use topical bio-signals to get the same physiologic effect as if more of these cells were present.

    Because the bone marrow stem cells of all human being produce identical bio-signals, there is no issue with “rejection” or allergic potential when they are used during microneedling. Cells, on the other hand, have different patterns of antigens on their membranes so tissue typing is important when bone marrow or other types of transplants are done (including blood transfusions.) There are no reported allergic reactions from any cell culture derived bio-signals applied topically to the skin. The first generation product has been sold for 13 years with a perfect safety record.

    • liane says:

      It seems like you are saying that microneedling causes inflammation, and that PRP causes inflammation (but a healing inflammation!), and that the two combined in the same treatment could be to be too much inflammation that could lead to hyper pigmentation or fibrosis if done too frequently. Is there data on this or is this just a theory? Would spacing the treatments further avoid the risk of hyper pigmentation and fibrosis, or would using red LED immediately after help reduce the inflammation? I really like the idea of PRP to boost collagen and elastin production to reduce the number of microneedling treatments required, but that’s just a theory of mine.

  8. Clelia says:

    Thanks for your response. I’m sure you will be doing extensive testing to see the reaction of the serum on the skin during and after microneedling. Looking forward to your published results.

  9. Susan Patashny says:

    Thank you for your very informative, detailed article. I am an Estethician, R.N. and Cosmetic Enhancement Artist. Where may I obtain more info on your product that is used in the microneedling process?

  10. Derek says:

    Interesting discussion and its very pleasing to see caution is being suggested with regards to skin needling, a couple of comments that I would make;

    Quote: “Cosmetic needling (0.2-0.3 mm) does not penetrate beyond the epidermis.”

    I am not sure how valid this suggestion is when we consider that the epidermis is less than 100µm in virtually all areas of the body that skin needling is likely be applied (i.e. excluding palmer surfaces). Even allowing a margin for skin recoil during mechanical treatments I would suggest that a needle depth of 200-300µm is still likely to penetrate into the outer dermis.

    Quote: “needling trauma is limited to the stratum corneum (uppermost) layer of the skin.”

    With the accuracy of needling equipment currently available on the market I think that it would be virtually impossible to restrict skin penetration to less than 20µm (i.e. the stratum corneum), even very superficial skin treatments are likely to penetrate this layer (peels, scrubs, abrasives).

    • drjohn says:

      Do not try to calculate penetration depths from needle length. It won’t add up, as you know. I don’t know the physics of why, but seems that the needle is not penetrating all the way to it’s hilt. I’ve seen the studies. Consult Dr. Setterfield’s book or course for details. You can find him on Facebook (Doc Setterfield) and ssk hime questions there also.

  11. Curious says:

    Thank you so much for the link to this article Dr. John. I think you may have saved me from making two foolish mistakes! I was planning on dermarolling this week. I have only done it a few times.

    ” Here is one gap: older people (like me) don’t mount the same cytokine & growth factor response as young people do. The older I get, the worse I perform. The older I get, the more prone I am to healing by fibrosis. The older I get, the more prone I am to releasing inflammatory cytokines, which can flip the switch from anabolic (volume restoring) to catabolic (tissue dissolving) growth factor profiles.”

    I am concerned about the point at which the above begins to occur. I definitely would not want to cause more harm than good.

    Also, I had no idea that the vampire facelift was inflammatory and thus, undesirable. I think I need to cross another procedure off my wishlist.

  12. Hello Dr. John,
    what a wonderful website! I have already gleaned a lot of useful information. Is your product useful for cosmetic needling or just medical needling? I would be very interested in learning more about your products and how to purchase them. I am a licensed esthetician. Thanks!

    • drjohn says:

      Kirsten, Both cosmetic and medical needling. In either case, the anti-inflammatory growth factors augment the natural regenerative response while preventing deleterious effects.

  13. jjm says:

    I had microneedling performed twice (Dermapen). I know have increased wrinkling on my face. I have severe damage around my lips and chin and now forming wrinkles on my face. Please help.

  14. Ashlee says:

    I’m so glad an acquaintance tried to sell me Nerium otherwise I would have never found this site. I have been microneedling with a .5 mm for a year, twice a week! Sometimes every other day. So I will start doing it every two weeks instead now. Also, I was following up with Vitamin C serum from Obagi and Cream De La Copper by Neova. I did get wonderful results, especially on the crow’s feet area, but I will contact a dermatologist to purchase your products. Thank you for taking the time to respond to everyone because I learned the most from your replies.

    Sincerely,
    Ashlee

  15. Ashlee says:

    OK, why can’t I find a Dr. that carries the MD version in my area? I hope I don’t have to drive to Seattle. I don’t want a non MD version. I want the strongest available. Any advice?

  16. Leah says:

    Yes Ashlee, I couldn’t agree more. I think I learned more from the responses. I am unclear though as to where I can find your product? I am so confused by the back and forth of YES create inflammation…. NO reduce the inflammation before they leave…. So confusing!
    I would how ever like to know your opinion on incorporating LED treatments at the end of the micro needling? Again there are a lot of opinions on it and they both make sense to me.

    Sincerely,

    Leah 🙂

    • drjohn says:

      Hi Leah, The answer is YES — microneedling (and really any physically invasive procedure) causes inflammation, which is OK if brief, but needs to be shut off ASAP to maximize the positive effects and minimize the possibility of negative. So – it is both good and bad – which can be confusing. It gets even more confusing when you consider age (the older we get, the less able we are to mount a proper, healing, rejuvenative response to the inflammatory event), skin type (darker skin has a propensity for hyperpigmentation in response to inflammation) depth of needling, and skin care routines aside from needling. Which is why it’s good to have a professional involved for “medical” needling, although we also endorse “cosmetic” needling as long as you are picky and do everything right. Anybody who can’t find a local doc who has AnteAGE microneedling solutions should contact us at docs@barefacedtruth.com – we will help you find one.

      P.S. The advanced lesson is this. We learned a decade or two ago from studying fetal wound healing that inflammation is absolutely NOT NECESSARY for repair of skin. That’s why a fetus can recover from intrauterine heart surgery, pop out at birth, and have a fully healing wound with ZERO scarring. Perfect regeneration. That’s our goal, to replicate the biochemical events of fetal NON-INFLAMMATORY wound healing.

      • Liane says:

        I also would like to know if using red LED immediately (633 nm at 130Joules/cm2) after micro needling would be beneficial. Do you have any data or insight?

  17. Rose says:

    Very interesting . I had an allergic reaction yesterday to microneedling where HA wax used . it happen a few hours after the procedure . I broke out in itcht red bumps , all over where the pen was used, I have sensitive skin and 1mm was used . Now I have used tazorac and done chemical peels in the past with No problems . I thought this procedure would be harmless with no down time . Well now I am on 25 mg of Benadryl 3 x a day and prenidose 10 mg , by the way the Benadryl makes me sleepy so basically I can’t function . Keep in mind I went to a triple board certify plastic surgeons office . I will stick to my retin-a , derma planning. . People should be made aware of the Risk and sign consents . These article was spot on. .. Thank you for writing it …

    • drjohn says:

      The HA molecule was probably not the culprit, but rather the wax used to bind it (or some other ingredient not natural to humans). We have a lot of educating to do in the professional community. Tell your physician about barefacedtruth.com.

  18. Shiraz says:

    This is the greatest blog ever and I am so glad I found it. I get pretty tired of having to hunt around and cobble together a full picture from 100 different sources and sift through conflicting information. What would you say to putting on fresh aloe right after needling? I mean fresh as in a leaf you just cut open. I have a big aloe plant so I have access to plenty of fresh gel to mush up and spread on my entire face. I cannot afford to buy your product now, as much as I would like to.

    • drjohn says:

      I would go with pure hyaluronic acid. It’s a truly human molecule, so unlikely to cause allergic reaction. Aloe is fine for topical but with needling more like shooting it up than rubbing it on. You can buy it for under $10. Make sure it’s pure. Try Amazon.

  19. Amanda says:

    Hello. I received my 1st microneedling, plus RF treatment on Monday and think you’ve explained why I have red, swollen, itchy bumps all over the areas treated. It’s pretty bad. I also have mini scabs from areas that are weeping fluid. I was only warned I’d look and feel as if I’d been sunburned. Monday night and Tuesday I was just that, red and warm in the face, but come Tuesday night, the tiny bumps were becoming raised. Up until then, all I used was a mild aloe cleanser and bacitracin zinc ointment the clinic provided. However, Wednesday morning I added a growth facter serum under the bacitracin. As the day went on the bumps looked worse and I had intense itching on my chest and face. Here it is Thursday and I expected to be healing and back to work. Not so much. I called the clinic and sent pictures to the medical director. He believes I had an allergic reaction. I’ve been prescribed methylprednisolone and told to stop all topical aftercare they provided. So here I am, researching why I had an allergic reaction as the cleanser and bacitracin didn’t make sense to me and bam, the growth factor serum’s 1st ingredient is snail venom! Man, I wish I read this 1st and didn’t drop $140 on extra serum for my face to say f you!! Any further suggestions to help heal and I pray don’t scar!?!

  20. I think as I have the world’s longest experience of skin needling and have personally done thousands of cases, I should make a comment. I have used vitamin A, C and other antioxidants right from the beginning in 1996 because my clinical studies with vitamin A and antioxidants from 1982 had shown me that vitamin A must be releasing growth factors – a detail that has only recently been proved in the laboratory. What can be more natural than using vitamin A etc on skin. Its naturally there in rich quantities provided you are not photodamaged. Since about 2007, I have used additional peptides on myself first and then on my patients skin immediately after needling. Higher up in this conversation there is an indication that I used vitamin A and C a long time ago before the huge clinical evidence had accumulated. Well, between Matthias Aust and myself I think we can rate ourselves amongst the most experienced people in the world of skin needling with thousands of cases. We have in fact largely made the clinical evidence of SAFE skin needling and I recommend our book “Percutaneous Collagen Induction” if you really want to understand needling. Virtually every case that I have needled over the past 20 years has used vitamin A and C etc immediately after needling and for a protracted period (for the rest of their lives…) after that. I have never seen a granuloma, I have never seen an allergic reaction etc etc. People just heal rapidly and get healthier skin. My “aggressive” regime is to needle the skin between 3 and 7 days interval for a six sessions. We are fortunate to be able to say that growth factor studies on humans is showing what Zeitter showed in rats: the growth factors increase as one needles more frequently. However, this will be the topic of a new report so I won’t elaborate further. I think my own face is a testament to this regime. I have had more than 70 needling treatments done between 2 to 7 days so I also talk from personal experience. In more than 5000 cases the use of Environ vitamin ACE Oil immediately after needling has proved to be safe. This fact cannot be ignored. The addition of selected matrix enhancing peptides, and hyaluronic acid helps to produce the finest results from skin needling in the world.

    • drjohn says:

      Welcome Dr. Fernandes. I would have said “welcome to the debate” but because I believe we agree about far more than we disagree, I think we should call it an advanced seminar addressing microneedling safety, efficacy, human biochemistry, cell biology, skin physiology, wound healing, and more! A virtual meeting. In fact I think we should move this to its own thread where we can share ideas on all these issues.

      Our particular goal is to elevate the field to a proper recognition of its value in aesthetic medicine. To do so, we need to address certain issues of particular importance to practitioners and patients alike. As microneedling as a primary treatment in cosmetic dermatology and surgery is growing rapidly, there are increasing numbers of reports of adverse reactions. We see these in journals, at professional meetings, and directly from readers of BFT as evidenced on these pages. Regulatory bodies in this country are taking more notice, as evidenced by non-compliance letters (nastygrams) to pen and roller makers, and restrictions on scope of practice in some states for who can perform treatments. As with any new modality, there will be questions that must be answered before it gains full “legitimacy” or acceptance as a primary tool. We believe that the industry in this country that is growing up around microneedling, and the physician opinion leaders, need to band together and form an “august body” of our own to 1. advance the science, 2. promulgate standards, 3. self-regulate. If we do not, it is pretty much guaranteed that government agencies will do the job for us – not the best solution if this modality is to survive and thrive.

      We all approach this phenomenon with our own background and experience. Yours as a cosmetic surgeon and pioneer is to be greatly valued. Dr Taylor and myself approach this from backgrounds in several disciplines of medicine, including diabetes (biochemistry of would healing), proteonomics, metabolomics and nutrition (I began as as a specialist and research doc & clinician in parenteral and enteral nutrition), stem cell science, and clinical aesthetics. We have initiated a research program with a microneedling focus and dedicated clinic. Dr Setterfield has his own unique background and experience, is a superb communicator, and travels the world gathering data while disseminating knowledge. This enables frameworks that are multidisciplinary & multidimensional – a very good thing in academic medicine.

      I suspect you will agree us and Dr. Setterfield and others that the major risks in microneedling have less to do with needling and more to do with adverse reactions to solutions placed on the skin at the time of maximal barrier function disruption. Snail secretions (xeno proteins) being the poster child. We advocate things that are physiologic and natural to humans, and at least theoretically helpful, for all the usual reasons. Vitamins (at least the molecular forms normally found in human biochemistry) fit the bill. Although timing in relationship to a classical wound healing paradigm might be a point of debate. Our own work focuses on human cytokines and growth factors under various conditions, about which there is much left to be learned. Our quest has been to take the foundational principles learned from biochemical studies of the mechanism of action of microneedling, which clearly pivots on the micro-wounding response, and look to optimize all this in the context of a regenerative therapeutic agenda. Our sense is that this is the most promising frontier upon which to build advances in the field.

      One simple minded example might be if vitamin A causes release of key growth factors, and that is a good thing, why not replicate what nature does by e.g. augmenting those pathways? During and between needling sessions. And to recognize that skin is not the same at all ages – the wounding response at age 70 is not what it was at age 20 years old (or 20 weeks gestational age). If we can mimic a more youthful skin response, why not go there? Then there are disease influences, and a host of other variables. Then there is the fact that there are literally hundreds of these chemicals working in concert – a complicated symphonic score.

      Again we thank you for participating in this seminar, and hope that you return with more of your thoughts and insights. We can all benefit from the interchange of ideas. The platform is yours…

    • Rita Gindi says:

      Just ordered both of your books Dr. Des…desperately need those products here in 365 day sunfest Miami!! Any chance of purchasing them soon? Can a plastic surgeon purchase them for his US office?
      Thanks!
      Rita , a big, VERY big fan! <3

  21. Roseanna Andres says:

    The first thing I notice in an interview with Dr.Des Fernandes is his extremely youthful and handsome lineless face. He is a living testimony to what dermaneedeling has done. The second thing I notice are his beautiful hands. Dr. Des will you marry me? Sorry guys, that face, sigh!

    • drjohn says:

      Roseanna, wasn’t it just a few days ago you were proposing to Drs George and John (simultaneously)?

  22. Jill Ann says:

    I am desperate for help after having 4 skin pen treatments, and developing Allergic Facial Granulomas Reaction. It has persisted for 2.5 months. My dermatologist had me on Doxycycline, topical corticosteroids, and things did “calm down” temporarily. However the Doxy made me ill. My rash back in full vengeance, and I am taking Bactrim, 10mg of Prednisone, and using Elidel for the past week. Since you have extensive experience with micro needling, I hope that you may have some suggestions and remedies. My dermatologist is at the top of her game, trying to rid me of this condition, “from the inside out”. It doesn’t seem to have any effect after one week. With gratitude. Jill Ann

    • drjohn says:

      Jill, sorry you are going through this. Can you provide details of the treatment: size/depth of needle, of you know that, and how far apart; any topical products used at the time or after treatment; any known allergies; any other details. Also can you send us a facial selfie (send to docs@barefacedtruth.com). We will put our heads together and see if we have any ideas.

  23. Ada says:

    I needled at home. I used an aloe lidocaine cream (for burns) from Walgreens along with an oral pain gel to help numb. It was a 2mm medical grade needle (per the sales flyer) and I went to down. I am olive skinned and can tolerate highest levels of retin A, chemical peels after derma planning etc quite well. For the past 3 days my skin seems to be it hire – bumpy and very rashly. I did use my TMS serum and Vit C after the treatment. I.m not sure what I should do. It’s not bleeding or “leaking” but the rashly bumps aren’t much better…pls let me know if this not so unusual. When should I panic and get to a doc. Shall I use hydrocortisone now or wait. I am on day 4. Thanks very much!

    • drjohn says:

      Ada – this could well be an allergic reaction to the serum or Vitamin C product. Some allergic reactions are mild and self-limited (a few days) others cause major deep problems and can last years (e.g. granulomatous dermatoses). We are about to report another two cases of granulomatous reactions. One was purportedly to a vitamin C product. Please take several pictures of your face and send them to us at docs@barefacedtruth.com. We would suggest you see a doc – preferably one familiar with microneedling and its potential problems. We keep encountering docs who are not at all.

  24. J Z says:

    Hi,

    I know that Dr. John has previously referred to mesenchymal stem cells, cytokines and growth factors in facial serums as “good things”, but not having the scientific knowledge required to discern the difference, what’s your opinion on ProCell Microneedling solution, which allegedly contains “cytokines and growth factors derived from bone marrow mesenchymal stem cell culture plus supplemental TGF beta-3 and IGF-1 from recombinant technology”? To me, naively, it sounds like it might be the same thing (as Dr. John recommended). I also read an article from Dr. Lance Setterfield cautioning application of anything other than saline solution or HA (which I know from you guys should be of high molecular weight, not low) immediately after microneedling to reduce likelihood of granulomas… would you guys think that some things that exist on the market today are safe to use even during and immediately after microneedling? Like for example this ProCell stuff? Thank you so much for your response, I appreciate your wonderful blog.

    Thanks.
    – J Z

    • drjohn says:

      The ProCell Microneedling Solution contain is exactly what we recommend (a formulation based on our science). We work very closely with Dr. Setterfield, and he in fact is part of our microneedling safety initiative. What he says is that you should not apply anything during microneedling that is not native to human biochemistry. Like hyaluronic acid. And like human cytokines & GFs. If you read him carefully you will note that he says that cytokines and growth factors are the future of skin care. We are joining forces with him on new educational modules about microneedling. More on this to come.

  25. Olivia says:

    Hi Dr.J,

    I would love to try one of your products or Procell product, but it seems that none of them are available to try here in Australia. I had my second dermapen treatment 24hours ago and really looking for suitable product for rejuvenation. Can you please advise me if your pruducts are available in Australia or recommend other commercial products to try?
    Will be very appreciated for your response.
    Olivia

    • drjohn says:

      Olivia – we are working now on distribution to Australia. Meanwhile I will pass your note along to Cellese customer service to make this available to you directly since there are no physicians in your area of whom we are aware.

  26. AJS says:

    Dr. J,

    I have a question regarding cosmetic needling (I did search BFT but I couldn’t find an answer to this specific circumstance):

    . I perform cosmetic needling twice a week (0.25mm) and I was wondering if it was appropriate to use the AnteAge serum during the actual process or if I should restrict my use to the home needling solution only. I do know that you advise caution as to application of some nominally topical products during microneedling due to potential inflammation and/or allergic response(s) but I don’t know if this is as common during a cosmetic needling at a shallow depth as I have described. My motivation for asking the question is financial; using 2 microneedling vials a week for my cosmetic procedures adds quite a bit more expense. I’m assuming that whether I use the needling solution or serum during cosmetic microneedling, I will still get improved delivery but if I negate that due to a (possibly unseen) inflammatory response then it obviously doesn’t make sense.

    Thank you for your time.
    —AJS

    • drjohn says:

      AJS, we recommend using only special microneedling solutions during home needling, and for at least 2 hours afterward (until the microchannels in your skin are resealed). Then apply AnteAge that evening and twice daily every day. The reason is that AnteAge daily serum and accelerator contain many ingredients other than human stem cell growth factors and cytokines, as they are designed for use on intact (not freshly needled) skin. If you are doing cosmetic microneedling (0.25mm) then the chances are quite small compared to medical (0.5mm & above). But we like to exercise caution. For home cosmetic needling the AnteAge microneedling solution can be used sparingly, since the holes aren’t deep. I would think that 2 cc could last for 6-8 sessions. If cost is an issue, you might use a pure, sterile 1% hyaluronic acid solution during needling to maintain a skin moisture barrier. Doesn’t provide the GF|cytokine infusion boost, but your daily AnteAge regenerative stimulus will still be amplified by the needling itself.

  27. Amanda says:

    I’m a Esthetician and professional laser technician in Texas. I have been performing microneedling treatment for the last 3 years with the Dermapen 3 and now the Eclipse Micropen. I have been using only HA during the treatment but have been researching the best product/compound to use during the treatment for melasma and hyper pigmentation. I would love to know what you would recommend.

    • drjohn says:

      Amanda, ask your Eclipse representative about their Glide-GF product for use during microneedling. It is identical to our own microneedling solution. Alone, and especially in combination with AnteAGE daily we have seen excellent results with all pigmentary problems.

  28. Jessica says:

    Hi All,
    Diagnosed with facial granulomatous inflammation reaction after mucroneedling therapy. I’m busy researching what exactly it is, quite upsetting. The treatment was with HA gel and a vit c serum. Will get more details, but that’s all I know for now. My dermatologist prescribed a strong antibiotic, Tetralysal 300mg as an anti-inflammatory. Have you gotten any further with positive responses to any treatments for what is essentially an allergic reaction? Any help or assistance for treatment etc would be appreciated.

  29. Melissa says:

    Hi there,
    Wondering how I get a hold of your products here in Australia. I am super excited to read all your articles!!!! Thankyou so much for showing us.
    Look forward to purchasing!

  30. I am an Esthetician in Longmont,CO…I’m looking for a dermatologist in my are where I can purchase Anteage..
    I’m so thankful to have found this site, because I’m interested in using quality products and learning the safety precautions to give myself & clients the best treatments with great results!

  31. Elizabeth says:

    Where can I buy your product ..living in San Diego now

    Thank you!!..

  32. Sharon says:

    I had micro needling with HA 6 days ago and I have had severe swelling in my face which has not gotten any better, no redness.

    Is severe swelling normal? Any idea how long swelling should last? or should I see a doctor?

  33. Giho says:

    Hi Drs,
    We have a distributor of MTS products ( clinical resolution) and they sell VITAL W to be used for medical micro needling . After reading your post, I am afraid to use this product during micro needling 1.5 to 2 mm , as it has many component and I think could easily cause an allergic reaction.
    I have a client tomorrow morning, do you have any experience about this product? I
    Saline solution would be safer? Or HA 1% high mol weight ?
    I have add the components of this products for reference.
    Maybe I could advise the use of this serum for day after treatment, although I will use body oil a-c from Dr Fernandes

    W Key Features:

    Acetyl Hexapeptide-3
    Matrixyl 3000
    Pentaxyl has wound healing properties
    Sodium Hyaluronate acid with its weight, 1Mda,
    EGF stimulates the growth of various epidermal and epithelial tissues in vivi and in vitro and of some fibroblasts in cell culture.
    Vitamin B5 reduces water loss through the skin after Microneedling
    Magnesium Ascorbyl Phosphate (MAP) is a vitamin C derivated
    Palmitoyl Tripeptide-28 is a stabilised peptide engineered for cutaneous delivery

    Please, I would appreciate your advice.
    Best regards
    Giho

    • drjohn says:

      Giho, we share your concerns about the potential allergens and other troublemakers (as Dr Lance Setterfield calls them) in this product. We have complained to this company in the past about the irrationality of their microneedling solution and its potential dangers but they chose to ignore us. Vitamin C can be a problem, as it was in 2 published cases, and we have seen two additional cases of granuloma with C containing solutions. Pure HA and saline would indeed be safer alternatives. Good on you for researching these products before using them.

  34. Anne says:

    Hello! This website is a well of knowledge, thank you! Question – what is your stance on microneedling over the lips? I’ve read mixed reviews and opinions. Does it help to plump?

    (I emailed privately as I’m also interested in carrying products for the surgeons office.)

    • drjohn says:

      Philtrim? Fine. You probably mean needling the mucous membrane side of the vermillion border. Some folks swear by it. Others say its not worth the pain (lips are very sensitive). Without a lot of data to back it up, I would say that 0.25-0.3mm would be safe enough.

  35. Max says:

    Dr. John,
    It’s been 3 1/2 months since I broke out in a rash, 9 days after my last skin penn treatment that included vitamin c seum. I have been taking Benadryl, strong topical steroids, doxycycline and still no change. Since this was basically a tattooing of an allergen, would a laser removal treatment resolve the inflammation. I had cared for my skin so diligently and the past months have been so difficult. Any help is greatly appreciated.
    Thank you,
    Max

    • drjohn says:

      Max: We have seen more serious allergic (granulomatous) reactions to vitamin C than any other substance. Sorry you are experiencing this. Laser not recommended – this is an acute inflammatory reaction. Continue on the treatment prescribed by your dermatologist. be patient – these things can take months to years to resolve.

  36. Anne Shirk says:

    So would collegan or Pure HA be safe during and after microneedling with a pen???

    • drjohn says:

      Pure HA is very safe as long as it is the high molecular weight variety (see the size matters post on this site). But read carefully to assure that there are no troublemakers in there as well. There should be a small amount of a safe preservative (e.g. benzylalcohol/DHA) but no other chemicals that are not native to human biochemistry (things that humans don’t make themselves). Collagen I would want to look at the source.

  37. Anne Shirk says:

    Can I use the Anteage Trial size during and after Mirconeedling with a micro needling pen???

    • drjohn says:

      Hi Anne, you shouldn’t use any product during microneedling that is not specifically designed to be safe for microneedling. For that we created a product called AnteAge Microneedling Solution. The trial size you refer to is the AnteAge Serum and Accelerator which is great to use after (wait at least 2 hours after cosmetic needling, and 4 hours after medical needling before applying).

  38. MPV says:

    Dese dr John
    I have mild Acne scaring, i Did 2 microneedling sessions with 1 mm dermaroller at home. The first one went great i Did minmized some rolling scars and boxcars that i had on my temples, i went excited by the results so the 2nd session i Did it 3 weeks after the 1st one. With the last one i used right after vitamin c Serum (Serum 15 from cell skin lab, HA from cell skin lab and a EGF & FGF Serum from OHL) the results from my last treatment didn’t go well because now the scars on my temples are more noticeable (wider and deeper) and in one rolling scar that i have is white, please i need help, it’s been 4 weeks now i got no swelling or redness, but i dont know what went wrong or if it’s temporary or i need more microneedling sessions to fix it or simply do not do it again and stay just the way it is now.
    Please i need help

  39. MPV says:

    Hi doctors:
    I did 2 sessions of microneedling 1mm al home, the first one went great it made some rolling scars and boxcars looked better on my temples, but the 2nd session i used serum 15 and HA from skin cell lab and EGF- FGF form O.H.L, and those scars that were improved at the begining, one of the a rolling scar turned deeper and white and the other some boxcars now are deeper. Please I need help, I don´t know how to fix that, should I perform another session of microneedling but this time do not apply anything.

    • drjohn says:

      MPV: we have never heard of skin cell lab. We easily found the EGF- FGF form O.H.L on Amazon. We looked at the ingredients list and immediately had one of those OMG experiences. This has so many potential skin allergens (troublemakers) it gives us shivers.

      Please, you need to read this post and this post here on BFT about complications of microneedling and what can cause them. The only things we recommend at the time of microneedling are molecules that are native and natural to humans, that have been handled properly (like HA that has not been digested into fragments, or cross linked, or otherwise made problematic) and that have proven aesthetic treatment benefits in the context of therapeutic micro-wounding to stimulate collagen induction (like human growth factors).

      Ingredients: Platinum Anti-Wrinkle Serum : Water, Aloe Barbadensis Leaf Juice,Butylene Glycol, Glycerine, Sodium Hyaluronate, Betaine, Bis-PEG/PPG16/16-PEG/PPG-16/16-Dimethicone, Caprylic/Capric Triglyceride,PEG-11 MethylEther Dimethicone, Olea Europaea (Olive) Fruit Oil, Portulaca Oleracea Extract, Betain, Beta-Glucan, Calendula Officinalis Flower Extract, Camellia Sinensis Leaf Extract, Acetyl Hexapeptide-8, Caprylyl Glycol, Capryl Hydroxamic Acid, Arginine, Carbomer, Tocopheryl Acetate, Polyacrylamide, C13-14 Isoparaffin, Laur eth-7, Allantoin,Copper Tripeptide 1, Macadamia Ternifolia Seed Oil, Simmondsia Chinensis(Jojoba) Seed Oil, Camellia Japonica Seed Oil, Platinum. EGF & FGF Whitening Serum : Water, Aloe Barbadensis Leaf Juice, Butylene Glycol, Glycerine, Sodium Hyaluronate, Arbutin, Betaine, Bis-PEG/PPG16/16-PEG/PPG-16/16-Dimethicone, Caprylic/Capric Triglyceride, PEG-11 Methyl Ether Dimethicone, Olea Europaea (Olive) Fruit Oil, Portulaca Oleracea Extract, Betain, Beta-Glucan, Morus Alba Root Extract, Camellia Sinensis Leaf Extract, Acetyl Hexapeptide-8, Caprylyl Glycol, Capryl Hydroxamic Acid, Calendula Officinalis Flower Extract,Laureth-7, Allantoin, Copper Tripeptide 1, Macadamia Ternifolia Se ed Oil, Simmondsia Chinensis(Jojoba) Seed Oil, Camellia Japonica Seed Oil, Human Oligopeptide-1, Hydroxyethylcellulose, Disodium EDTA, Human Oligopeptide-13, Adenosine, Dipotassium Glycyrrhizate, Retinyl Palmitate, Ceramide 3, Fragrance.

      We are getting more and more readers writing to us about microneedling complications. Some are simple, but a growing number are devastating skin problems like granulomas. Dr. Setterfield is going to join me in a mutual “call to arms” to try to stop these dangerous practices. Will publish here soon. meanwhile – anyone with any problems related to microneedling please write to us as we are building a database that we hope will help doctors and consumers to avoid these nasty problems.

    • drjohn says:

      Don’t do anything for now. let your skin rest. Immediately take some pictures and e-mail then to us here – docs@barefacedtruth.com.

  40. JRM says:

    I must commend you on having the BEST website I have seen on micro needling! I have researched so much as I’m considering starting it, first at home for cosmetic depths then see how my skin reacts and doing professional needling at a dr’s office. My first question of concern is I’m 63 yrs old with pretty good skin with the usual complaints of aging. Will micro needling with the correct products use really help? or because of my age and repair it wont help? Also, what are your views on the many ( and some good ones) electronic micro needling pens for home use?
    Thank you so much for your most valued input!

    JRM

    • drjohn says:

      JRM, My sense is that the older you are, the more dramatic the difference you might see. These pictures are from a 74 year old woman (10 years older than you) who underwent microneedling plus our stuff (bone marrow derived stem cell growth factors). Four sessions, about a month apart. The results speak for themselves.

      Before After

  41. Claire says:

    Hello Drs! I did my first micro needling at home using a 1mm dermastamp on my neck. I have horizontal lines and I am hoping that a dermastamp might help over time. I also have a faint line on the clavicle. Have you heard of any success on the neck?? Particularly with horizontal neck lines? I am 35 years old. I am also told that I may want to try radio frequency treatments Endymed but its cost prohibitive for me at this time. I have only dermastamped once and so far no change observed. I have read that it can take 6 months or more to see a difference. Would you recommend to continue dermastampingon the neck? I am not interested in fillers like Botox or Restalyne.

    • drjohn says:

      Hi Claire, Needling & stamping has a good track record for neck issues, including horizontal lines. But it does take time (many months)
      microneedling - neck
      RF is definitely effective. You would need probably 3 treatments at 3 week intervals, for which you need to save up ~$1000. We use the Venus Viva in combination with AnteAge in our research clinic.

  42. SuzieQ says:

    A couple of years ago, I had a 8 Venus Freeze treatments done on my face. It did absolutely nothing for it. Pictures were taken before and after and there was no improvement whatsoever. Do you believe for some people that RF does not work? I guess the same way microneedling may not work for some either.

    • drjohn says:

      SuzieQ, it’s possible I suppose, but must be exceptionally rare. We have reviewed the extensive clinical evidence base, and find RF to be a proven safe and effective modality for facial dermal rejuvenation. Now there are issues of dosing (more is generally better) and what you apply afterward (some skin care ingredients may inhibit rather than promote a positive aesthetic result). We use the Venus Viva in our research clinic. The protocol there involves test patches prior to treatment to determine the correct dosing. You might consider going back to the clinic where you had this done, and ask for a free or fee-reduced “make up session” or “redo”. I know at our clinic we want everyone to be satisfied customers. If you do, make sure you also ask for the new Venus Skin products (including an RF recovery kit) which are based on the latest science for stem cell derived cytokine/GF rejuvenation.

  43. SuzieQ says:

    Thanks for your quick answer. I also have another couple of questions. I have started Anteage about 3 weeks ago and can’t find an answer about vitamin c and anteage. Do I apply them separately and if so, how far apart (as in minutes)?:? Also, can a copper peptide be used with anteage at the same time? I don’t want to cancel out the effects of each product.

    Also, in regards to RF, what do you think of INFINI RF? It is a microneedling procedure with RF. Since the Venus Freeze didn’t work for me, I am a little leary of trying anything else with RF. I do microneedling on myself every 6 weeks or so but thought this might be even more effective for sagging skin. Thank you!

    • drjohn says:

      We haven’t tried Infini RF. We do use the Venus Viva RF with superb results (there is a recovery kit for that procedure based on our technology). Vitamin C is already in AnteAge. You can use more if you want – separate by at least 5 minutes.

      Copper peptide is a copper complexed GHK. The GHK peptide is already in AnteAge. However we use a non-copper complexed version as we think copper is not necessary and may even be detrimental in some circumstances. I will cut & paste some recent comments we have made regarding copper GHK.

      Gly-His-Lys (GHK) and their copper complexes are physiologic (occur naturally in humans) and have demonstrated anti-inflammatory and antioxidant effects. Effects on wound healing, tissue repair and skin inflammation have been demonstrated – possibly mediated through stem cells and their paracrine secretions (growth factors). GHK has a strong affinity for copper. The GHK-Cu complex is found in human plasma. But the unbound GHK is fully functional on its own. As you may know, there is considerable controversy concerning copper peptides whether slathering the copper bound variety is necessary, or even harmful. Many people report copper peptide “uglies” which could relate to this factor (the copper bound variety is NOT natural to skin). Both GHK and GHK-Cu are quite polar and absorption through the epidermis is minimal. Copper peptides do stimulate fibroblasts to produce more collagen, but they do so indirectly by affecting of number of regenerative cytokines. It is not a “single growth factor” treatment like EGF in isolation. GHK is not directly mitogenic, and is not associated with cancer. In fact it has positive effects on caspase, growth regulatory, and DNA repair genes that are associated with cancer suppression. The only issue I have with copper peptide is the copper part. The GKH part is clearly associated with many of the same good things as mesenchymal stem cells cytokines and growth factors.

      Matrixyl 3000 is a combination of two peptides in palmitoyl (lipid conjugated) form. Th primary one is GHK (or pal-GHK when attached to the lipid). The same peptide linked to a copper molecule is call Cu-GHK or copper peptide. GHK has been widely researched over several decades. Much is known about it’s biochemistry. It is both safe and effective, for wrinkles the clinical studies suggest about 30% efficacy. It modules multiple cellular pathways in skin rejuvenation. It is anti-inflammatory. We include it in AnteAge as it has good synergy with stem cell biology, particularly involving integrins. As with most collagen stimulating substances, the type of collagen created will depend largely on the surrounding milieu – if inflammation is present the collagen tends to become poorly cross linked. If inflammation is tamed, then good basketweave collagen and elastin can result. All collagen you make on your own is natural.

  44. G says:

    Why does ascorbic acid cause allergic reactions after needling, given that it occurs naturally in the epidermis? Or do only the other vit C forms cause allergic reactions?

    Thanks in advance.

    • drjohn says:

      Probably the non-native versions of Vit C used in skin care… there are lots of them on the market.

      A few references:
      Allergic contact dermatitis caused by 3-o-ethyl-L-ascorbic acid (vitamin C ethyl).
      Contact dermatitis caused by ascorbyl tetraisopalmitate in a cream used for the management of atopic dermatitis.

  45. JRM says:

    When micro needling at home and using pure HA solution during needling would you say it’s safe to use your Anteage serum immediately after the needling OR would you recommend waiting at least 2hr? I just at this time can’t afford your micro needling solution that I would love to get! so looking for alternatives to good results

    JRM

    • drjohn says:

      You should wait a few hours. Unlike the microneedling solution (pure HA and stem cell growth factors), the serum contains other molecules that are not native to humans. Please let us know how you do with your needling! We are so impressed with what we see in the clinic these days.

  46. Ivana says:

    Hi,
    first of all, thank you very much for all the great information on your website! I have a question about microneedling post-treatment. I’d just had my first microneedling + RF session (I think that the machine is called Flora), and the beautician applied Avene Cicalfate on my face right after the treatment. I did not have any adverse reactions, but it does not feel right to me, especially because it contains mineral oil (paraffinum liquidum). What would you recommend to use immediately after treatment (that is available in Europe)? I would be happy to buy your products, if that’s possible. Thank you very much, Ivana

    • drjohn says:

      Hi Ivana. Agree that mineral oil is NOT something to put on your face right after microneedling. It can cause foreign body inclusion cysts to form. Paraffin is not a human molecule, to be sure. I would recommend plain hyaluronic acid with nothing else during that critical few hours after microneedling. AnteAge technology based products will be available in Europe in just a few months. We will announce them here.

  47. PK says:

    Hi, amazing site and so much useful information, thank you. I am suffering from acne scarring on my cheeks and I have been trying to get rid of them in the last few years by dermarolling and stampig combination. The progress is very slow, probably because I am in my early 40’s and scars (rolling and icepick) are a bit deep. I recently bought the derminator which I am very excited about, my questions are;

    I want to make sure I use the best serums to accommodate derma-needling to reduce my scars to minimum and I recently come across the AnteAGE and Procell serums.

    Which would you recommend for scarring?

    I live in London how can I purchase the MD versions of these products and if I can not, would I see the same results with non MD solutions. You mentioned above you have been seeing impressive results with derma needling and AnteAGE but are they results achived with the MD version? Is non MD version is simply for wrinkles and pigmentation?

    If I was to purchase the three serum set (needling solution, serum and accelerator) would you still recommend I use separate serums like vitamin A,C,E, Pure Hyaluronic Acid, Copper Peptides? If so which brands please?

    Thank you very much

    • drjohn says:

      Hi PK, As you are in London and we don’t yet have a presence there, DrGeorge will be your “distance doc” (we are actually working on adopting a software platform for such things). The MD version has a higher concentration of the key cytokines and growth factors needed for scar revisions. Yes to the AnteAge system (microneedling solution, serum and accelerator) but you won’t need recommend the others because 1) you should never use non-native human molecules, which some of these products contain at the time of microneedling, and 2) the AnteAge system serum & accelerator used between sessions contains all those things (except instead of Cu++ GHK we prefer the copper free version of GHK as copper can be an inflammatory under some circumstances).

      • PK says:

        Thank you very much Dr John, now that I have my AnteAGE needling solutions and the two serums I would like to get it absolutely right. I am planing to use the derminator derma stamp device with 0.5 mm on my forehead, 1.5mm on my cheeks since I have scarring on my cheeks, what do you think? Also during the needling my skin bleeds a lot, since the micro-channels will be open, what would you recommend me to use to wipe the blood off? I wouldn’t want to wipe the serum off of my skin in the process, how do you manage this kind off situation?

        Thank you very much.

        • drgeorge says:

          Drgeorge, here. As far as needling length goes, the 0.5 mm sounds adequate except where you are treating scars. There, longer needles will be helpful. Dr. Lance Setterfield, an international recognized microneedling guru and author of The Concise Guide to Dermal Needling feels 0.5 mm is adequate to promote collagenesis and without a specific indication for longer needles, routinely uses o.5 mm.

          Because you mentioned there is significant bleeding, I presume you are using topical anesthetic (or are a tough lady) and disinfecting well with alcohol after thorough cleansing. We recommend wiping the blood off with sterile gauze and perhaps a little normal saline. It is not necessary to use Microneedling Solution during the treatment although many people do. Dr. Setterfield himself uses normal saline. Mircroneedling solution can also be used as lubrication but wiping will remove some. Certainly, once the treatment is completed, the Microneedling Solution should be applied every 15-30 minutes until the roller-ball vial is empty. You want to apply it while the microscopic needle perforations are open. They seal off in just a few hours, so applying product while they remain open is optimal.

  48. SImon H. says:

    Dear John, a few weeks ago I bought the iBeauty Pen. So far, I used the tria laser as well as tripollar radiofrequency. Is it necessary before I start with the Microneedling to watch the Needling Guide Online Course by Dr. Lance Setterfield? Or are there other sources that are helpful to the successful Home Microneedling? As for the products to a successful treatment. What products at what time are necessary from AnteAge? Until now, I used the Nutri-Active Day Cream from Oskia London as well as Keys Solar Solar Rx – Moisturizer with SPF 30+ Broad Spectrum UVA-UVB Protection. May I ask what sun-protection you recommend for the Microneedling, SHIELD Zinc Oxide 21% of Bellus Medical ?, and which anesthetic cream, disinfectant? What needle depth do you recommend for the first Microneedling treatment? Thank you very much dear Dr. John for all your me so helpful work on this side. Certainly would not have been possible for me without all your researches and helpful advice to carry out a successful Microneedling. Thanks again! Kind regards Simon

  49. Mr.Handel says:

    Hi Docs,
    I am a bit confused about advice on how to proceed with a microneedling treatment.
    On the one hand, I have heard that 3 weeks before the treatment ENVIRON – A, C & E Oil 100ml should be applied,
    but am not convinced by the ingredients of this product.

    Content:
    Bht, cosmetics
    Very questionable
    Functions
    ANTIOXIDANT
    Inhibits oxygen-promoted reactions, preventing oxidation and rancidity.
    MASKING
    Reduces or restricts the basic odor or flavor of the product.
    Problems
    Promotes cancer. Suspected hormonal efficacy.
    DATA SOURCES
    European Commission, Cosmetic Ingredients & Substances
    TEDX, The Endocrine Disruption Exchange, http://endocrinedisruption.org/endocrine-disruption/tedx-list-of-potential-
    endocrine-disruptors/chemicalsearch? (13.07.16)
    Consumer Center, Cosmetics: How the ingredients work, https://www.verbraucherzentrale.de/kosmetik (Stand: 02.11.2015)

    What do you advise me from your experience of what products should be used for Micro-needling treatment?
    Does the facial skin have to be treated with a vitamin cream before treatment for some weeks or not?
    Which product is best served during the treatment and immediately afterwards, as well as in the following days?
    Regards Mr. Handel

    • drgeorge says:

      Regular readers of BFT are aware that Drjohn and Drgeorge developed a microneedling solution in consultation with Dr. Lance Setterfield, author of The Concise Guide to Dermal Needling. It is intended for use during and/or immediately after microneedling treatments (AnteAGE Microneedling Solution). It contains conditioned media from cultured human bone marrow stem cells (the miracle cells that control healing and modulate inflammation throughout the body), hyaluronic acid plus a commonly used preservative system to keep it fresh and prevent microbial growth. These preservatives are used globally in a variety or parenteral (injectable) medications and vaccines. There are no cells or cell parts in the product, just the bio-signals (cytokines and growth factors) they produce in culture. (A summary article URL about preservatives is below.)

      AnteAGE MD Microneedling Solution also contains synthesized human TGF-beta3, a particularly potent anti-inflammatory bio-signal. It can be obtained from physician practices (contact BFT to find the name of a provider near you.)

      Both of these products are intended for use during and/or immediately within the first hour or so after the treatment. As far as optimizing skin prior to microneedling, we favor AnteAGE and AnteAGE MD Serum & Accelerator. We have seen very impressive photos of people who have used the Serum and Accelerator, along with two, three, or more microneedling treatments at one month intervals. Most importantly, however, it is recommended that no products be applied to microneedled skin that are not specifically formulated for that purpose. We have seen some very nasty reactions, including granulomatous fibromatosis, in people who have applied substances to their skin that are foreign substances not native to skin. All the components in our microneedling solutions are proved safe with many scores of thousands of treatments having been administered without report of a single adverse event.

      J Pharm Sci. 2007 Dec;96(12):3155-67.
      Antimicrobial preservative use in parenteral products: past and present. https://www.ncbi.nlm.nih.gov/pubmed/17722087

  50. babs says:

    Hi, Did anyone answer Jim, whose skin looks worse after the microneedling? The skin around my mouth and on my chin definitely looks worse…marionette lines and fine lines (“tram and track”) that were not visable prior to the needling and a definite droop on the right side of my mouth. I am 63. The rest of my face looks fine, but I wouldn’t say better … the needling hurt terribly and I had red skin for two full days. I had a cut in one of the crow’s feet next to my left eye, bruising across my left cheek and a raised red spot on the bridge of my nose and at the hairline. My skin then flaked and peeled. I had this procedure done in a well-known and respected derm’s office. She used HA. It felt like my skin was being ripped off my face. I am very fair, take no medications, am in good health and followed all the instructions/protocols they gave me for the follow-up care. I’m not a chicken about pain, but I’m telling you – this REALLY hurt. And I am distressed about the way my mouth looks. Derm is denying that needling makes you look worse… It’s been 2 weeks since I had this done.

    • drjohn says:

      Hi babs. I’m wondering what depth of needling (needle length) was done. To be sure, Dr. Lance Setterfield and I have been compiling cases of microneedling gone awry, and while quite rare I can say with some confidence that it is possible to look worse after microneedling. Usually it resolves over time. In your case it does not sound like a reaction to chemicals applied at the time of microneedling (these are more common – you can see documentation of several of those here on BFT). Perhaps you received an overly vigorous needling for your skin type and age. This can relate to depth of needling, the brand of pen involved (some cause drag during pen motion, which can distort the skin and amplify needle puncture injury). Current theory suggests that the needling end point of a treatment session should not be bleeding, raw skin that stays red for two days. In fact, when using stem cytokines along with microneedling, we are seeing resolution of redness within hours, not days. And with newer pen designs Dr. Setterfield is reporting minimal bleeding and less trauma and pain to the point that topical anesthesia is not often required. The most troublesome symptom you mention is the definite droop on the right side of your mouth. That can be a sign of nerve damage, although that would be considered a very rare occurrence with needling since the needles aren’t long enough to get into the dermal layer where motor nerves to the corners of the mouth are present. But not everybody’s skin is the same thickness, so it is possible to penetrate to that level with a 1.5mm or 2.0 mm needle in an older, fair-haired person, whose skin is perhaps a bit thinner than “average”. The pain you mention could be a clue in that direction as well. We would suggest that you follow up with your physician to allow them to evaluate this symptom within the context of your treatment. The other observations such as bruising, flaking and peeling suggests an overall high level of inflammation to the skin that may still be resolving. Microneedling is meant to be “fractional” which means there is enough non-damaged tissue to heal the micro wounds of needling quickly. But these concepts are all relative – each person has a unique physiology so that “not all skin is the same”.

  51. babs says:

    Thank you for the quick response. She used .8 on my forehead and 2.0 on my cheeks (ouch). They use needles up to 3.0. Still waiting for a response regarding what size they used around my mouth. They left the numbing cream on my face for only ten minutes. I asked if I could have it on longer, and she said ‘it doesn’t work if you leave it on longer than that.’…no wonder I had so much pain. Everything else I have read says that the patient has the lidocaine on for up to an hour….I didn’t mention before that my skin texture is now very rough when before it was very smooth, despite the wrinkles. I am seeing the doctor this week. She recommended the needling and she has been great with the filler – I had no reason to expect that the needling would be so different from what everyone else seems to be doing (at least on the internet postings).

    • drjohn says:

      babs, ouch is right! Dr Setterfield’s latest recommendations are to needle just to, but not through, the dermal-epidermal junction. Which in practice means 0.5 mm needles for facial needling. The only time to go deeper is with scar revision treatments. The skin thickness of cheeks on average is only about 1.2- to 1.5mm. Needle length is not precisely the same as degree of penetration, as it somewhat depends on pend design, and operator technique. I will share your story with Dr Setterfield today and see what he has to add.

    • DrLance says:

      Dr Lance Setterfield adds: Hopefully she is just using bad products containing something like glycerin and lives in a dry climate causing excessive TEWL after the needling to make the wrinkles appear worse. In 1-3 months she will have her answer. She has only just started making new collagen. However the droop is concerning. I have had one case referred to me where the patient sustained a facial nerve injury after a 2 mm needling. Interesting that this patient describes bruising on the left, but droop on the right. Hopefully her droop is due to a temporary neuropraxia secondary to swelling and not a direct hit. Again, time will tell, but perhaps she should see a neurologist to see if she needs steroid treatment to alleviate swelling around the nerve or something else that can spare the nerve any further damage.

  52. babs says:

    Hello Again, I am using top of the line HA products and moisturizers for my face, trying to stay hydrated etc. The wrinkling around my mouth started becoming very obvious a week after the needling. My left side always bruises and reacts when I have treatments but then responds better. I think she was overly aggressive with my skin and I certainly was not given adequate pain control. She used 2.0 around my mouth.Ouch again. I am seriously considering cancelling the rest of the appointments (for which I paid in advance, of course). This has made me look 10 years older. Very disappointing. I will wait a month to see if it improves, but feeling doubtful about that. I did it for the fine lines on my upper lip but those are the same and everything else looks worse. Now, add the expense of a neurologist to the expense of a failed cosmetic endeavor……caveat emptor.

  53. Sarah Gontijo says:

    Hi,

    After all, which serum do you recommend to use during and right after the microneedleing procedure? I know you recommend HMHA but any specific brand? Does AnteAge has one?

    • drjohn says:

      AnteAge has a microneedling solution designed for just that purpose. You use it both during and immediately after. It is based on native human growth factors and matrix proteins, so it amplifies the microneedling effect without risk of allergic reaction.

  54. Nadja says:

    Hi, I’ve had my first needling session done a few weeks ago at a cosmetic practice by a dermal therapist. 2.0mm depth was used all over my face at my request. I’m a regular user of chemical peels and very active skincare and my skin is super tolerant. At the time of treatment I had a small hormonal outbreak of pimples next to my mouth that was nearly all healed up. The compounded top Anastasia was slathered on thinkly and a second cost reapplied 10 min later. All up it was left on my skin for only 20min – or so I thought! Once the session was over I’ve asked the therapist what product she used for a gliding agent. She said that she left the topical anaesthetic cream on and needled with that on. I knew that’s wasnt right as I’m a sales rep for LMX4 numbing cream! I made many phone calls to the management and main office who manage these nationwide clinics but am yet to be contacted back. The small outbreak spot turned into a massive bacterial infection one week later that needed a doctor and Bactroban ointment. 2weeks later it is now healed finally but some PIP remains. I am still in shock about leaving top anaesthetic on and wondering if it might have done me any long term damage?

    • drgeorge says:

      The long-term damage is what you are already dealing with IF the inflammation has subsided and does not return. PIH from microneedling is something I have not yet encountered from anyone. Certainly, the technique used i.e. leaving on a topical anesthetic sets the stage for entry of very NON-physiologic substances (the ingredients of the anesthetic that are the non-active ingredients) into a “raw” surface. Microneedling is very safe IF done correctly, and can lead to long-term negative results if done wrong.

  55. Doris gelvan says:

    Do you know of a physician or esthetic Ian who I can see with confidence that has experience in microneedling. After reading all the responses I am very concerned about whi to select for this procedure. I live in Short Hills N.J. I would b willing to travel for the appriate person

    • drgeorge says:

      Doris, microneedling is a reasonably straight forward procedure that can provide great benefit. The indications (scars, pigment, rejuvenation, etc.) largely determine optimal needle depth and aggressiveness of treatment. With good hygienic practices and equipment, it is a remarkably safe procedure IF precautions are taken not to slather the WRONG products on the skin during and immediately afterwards. That is where things go awry. We STRONGLY suggest that only products containing naturally occurring substances be applied to the skin while is is “raw” from the trauma. We are aware of people who have had serious negative reactions to topically applied products not intended for application to a raw surface. Examples are vitamin C serum, a hyaluronic acid product, and products containing so-called snail “growth factors”.

  56. Anna says:

    Hello doctors, I spent my whole afternoon reading this blog carefully. I am almost graduated in medicine too and I had 3 1.5 mm needling treatments in my face (self-made). I was concerned about the possibility of allergic reactions even before reading this because it seems my skin has become more sensitive after these treatments, and now my fears have been confirmed. I want to needle my skin again because of some moderate acne scars and I’d like to know which products should I use exactly, which are avaiable in Italy. So my questions are:
    1- In my past treatments I used a skin desenfectant before needling which has these ingredients: Benzalkonium chloride (250 g). Excipients: nonionic surfactant, 2-bromo-2-nitro-1, 3-propanediol, perfume, colorants, sequestrants, deionized water. Is it safe to apply just before needling or what should I use instead of this?
    2- I used to wash my dermaroller (after disinfecting and before needling my skin) with bottled water or spray thermal water like Avène’s one. Is this a bad habit?
    3- I wanted to know if applying vitamin C products the days before needling could cause allergic reaction itself and if I can apply only thermal water or saline right after the treatment to minimize the risk of allergic reactions and then vitamines oil after some hours.
    Thank you if you have read up to this point and sorry for my (probably) bad english! I’m looking forward for your answer, thanks again for what you do!
    Yours Anna.

    • drgeorge says:

      Hello, Anna.

      When it comes to cleaning skin, and avoiding problems with microneedling, we suggest “keep it simple” and by all means stay away from products containing perfume, colorants and the like. Washing with a quality cleanser and rinsing well, followed by a robust wipe with rubbing alcohol is more than enough. (Just like what the doctor or nurse does before an injection.)

      If you are needling with 1.5 mm devices, I presume you are applying a topical anesthetic. If so, be sure it is thoroughly removed, again using alcohol wipe. Allow time for the alcohol to evaporate.

      As far as dermaroller / stamp disinfecting, an alcohol soak will suffice. We have also heard of Polident (denture cleaning tablets) being used, then alcohol and a good rinse prior to needling.

      We are wary of applying anything during or immediately after ( at least 6 hours) to the skin that is not physiologic and composed of ingredients that are physiologic and found naturally within the skin. The issue with using anything else, including vitamin serums, is that there will be non-natural and non-physiologic ingredients in the formulation. Remember, these products are NOT formulated to be used on raw skin surfaces – which is what microneedling creates. Thousands of tiny raw surfaces. In fact, we have seen serious long-term adverse effects from vitamin C serum and even hyaluronic acid products, again because they contain non-physiologic ingredients.

      Wearing our commercial hats (AnteAGE and AnteAGE MD) we created microneedling solutions in consultation with Dr. Lance Setterfield, an internationally recognized expert in the field. These have been used more than 100,000 times without report of an adverse event. They contain ONLY physiologic ingredients found naturally within the skin. They are used during and/or immediately after needling and help promote healing while minimizing the inflammatory response. Clinical results have been quite spectacular, especially when combined with our daily anti-aging products.

      If you would care to try these products, let us know by reply.

  57. ET says:

    I am 60 and have had 3 microneedlings done in a series of 6 done every 4 weeks. This is being done in a dermatologist office using a micro pen and the Anteage MD needling solution.
    I have a few wrinkle starting on the upper lip and skin is just starting to jowl.

    I use Anteage MD serum AM & PM
    I can’t use the Anteage Accelerator vitamin E makes me break out
    Here is my regime
    AM Anteage MD serum & sunscreen spf50
    PM Anteage MD serum 1 hour later I apply Tretinoin cream .05% blender hydroquinone 4%
    Since I can’t use the accelerator I would appreciate your thoughts/suggestions to get the best results possible
    Thank you

    • drgeorge says:

      It is difficult to suggest an optimal regimen to use with microneedling and general skincare since, as your sensitivity to vitamin E attests, everyone’s skin is unique. What is clear is use of AnteAGE brand (AnteAGE, AnteAGE MD, and HOME) microneedling solutions is very unlikely to result in issues since all ingredient are physiologic and found within skin except for the preservative system, which is globally accepted and even used in vaccines and other drugs. 100,000+ doses used without report of an adverse event. We are not huge fans of hydroquinone and plan to develop a lightening product. Too many questions about it.

  58. Kim says:

    Hello Drs,
    I have just completed a “test run” of micro needling (1 mm size) on one of my legs above the knee where the skin is saggy, just to see how my skin reacts as I tend to have somewhat sensitive skin 1 will only be using 5 mm on my face. I regularly use AnteAge MD on my face, and I used 1 vial of the AnteAge micro needling solution on my leg. From reading your previous responses, I understand that nothing non-physiologic should be used for 6 hrs or so after micro needling, but that 100% Hyularonic acid is ok. I have read the label on the bottle of HA I have and think it’s ok, but since these things aren’t really regulated, I just want to get your opinion of this product if possible. It’s Watt’s Beauty 100%Hyaluronic Acid – stated ingredients are water, Hyaluronic acid (plant sourced) and natural preservative (fermented radish). Do you think this would be an acceptable product to use during/after microneedling, and if not can you point me in the direction of an HA that would be appropriate to use? Thank you!

    • drgeorge says:

      The more simple the ingredient deck the better, as long as ingredients are “physiologic” i.e. found naturally within skin. Rather that opine that all is well with this or that product (something we cannot do), we suggest you consider a “test patch” somewhere less visible (not on your face) and see if a reaction occurs. By all means, stay away from complex ingredient decks where it would be impossible to tell what is the offending ingredient if something does go awry.

  59. Irish says:

    hi, can I use AnteAge Serum not the MD version during microneedling? what is the difference beteen the two? is pure Silicon ok to use as after care? or vitamin E capsules?

    • drgeorge says:

      We need to be clear which product you are asking about. Wearing our other hat, that of manufacturer of skincare products, we produce AnteAGE MD, AnteAGE, and AnteAGE HOME Microneedling Solution – all are suitable for microneedling. They contain physiologic ingredients, ones that are naturally found within human skin, along with a universally accepted preservative system, which is also used in vaccines and parenteral (i.e.”injectable” products.) We DO NOT recommend using AnteAGE MD or AnteAGE Serum during or within several (6-8) hours of microneedling. The serum products contain many ingredients not naturally found within human skin.

      We would definitely NOT recommend use of pure silicone or vitamin E capsules with microneedling. One must be careful what substances are applied to skin that has had its barrier function substantially compromised, as occurs with microneedling. We are aware of a number of adverse events (granulomatous dermatitis) when vitamin c serum, hyaluronic acid, and snail derived “growth factors” were applied after microneedling. While these are uncommon events, one must remember that nearly all products have multiple ingredients and some have no place being “injected” into living tissue. Bad idea IOHO.

  60. Debbra says:

    Hi Drs,

    I’ve been reading and am contemplating at home microneedling. I think you’ve saved me some trouble since I was planning on using vitamin CE after a session, now I will not. Thank you

    I have skin of color (caramel/cinnamon) and am treating hyperpigmentation via sun damage. I’ve been using Skinmedica retinol .5, Vit CE Ferulic, Elta/Obagi/Skinceuticals sunscreens, and light chemicals peels for the past 11 months and have seen good improvement; however I would like to get more improvement without damaging my skin or increasing inflammation. Hence the desire to try microneedling. My dermatologist wants to proceed with a series of Clear & Brilliant Permea treatments, but I’m leary of lasers for my skin tone. To me it seems that microneedling is a manual sort of Clear & Brilliant Permea without the heat.

    My questions:
    1) I have a .5 micro roller from OwnDoc and plan to roll once a month. Would this, in theory, help with sun damage/hyperpigmentation?

    2) Would the AnteAGE microneedling solution expedite the removal of hyperpigmentation?

    3) I live in Montgomery County, Maryland. Do you know of any doctors who carry AnteAGE?

    4) Does the microneedling solution contain any actual human fluids/particles that could spread (human) infections? I’ve always been interested in growth factors and stem cells, but when I read about the origin of some, it’s scary since they are from human tissue.

    Thank you for your time.

    • drgeorge says:

      Hi, Debbra. Not sure how we missed these very good questions last month but here goes.

      Answering your questions:

      1. We are great fans of microneedling, whether done with dermarollers or more sophisticated electrically powered oscillating needles. The purpose is creating controlled trauma anticipating that the skin will heal with fresh cells, rejuvenating the skin. Pigmentation is one of the indications, but you are right, with your skin type you definitely want to minimize and exit the inflammatory phase of healing quickly.

      2. Our microneedling products have proved quite effective at reducing the inflammatory response following microneedling skin trauma. If your pigmentation is not in the deeper layers of the skin, it may well help expedite resolution. Reduced post-traumatic inflammation will certainly help in preventing additional PIH.

      3. All cells and cell parts are long gone as they are filtered out in the laboratory before the cell culture broth (conditioned media) is used in any of our products. As far as being from “human tissue”, I don’t understand how that is a problem. Human cells produce human growth factors and cytokines. So-called plant “stem cells” we consider a marketing scam. An apple tree is not going to produce bio-signals that your cell membrane receptors will respond to. We also advocate steering way clear of snail derived products. There is a >50% cross reactivity to dust mite proteins and snail so the incidence of allergic reaction is huge. As far as disease spread with topical human cell culture derived product, some fifteen years and millions of doses later, there is not a single documented case of disease transmission that we can find. We searched Google Scholar, PubMed (the global internet medical library, and the FDA data bases. Topical growth factors and cytokines derived from human cell laboratory culture have proved exceedingly safe.

  61. Debbra says:

    Hi Drs,

    What do you think of the Procell Livra Wand (their at home microneedle wand)? Is it effective for driving products deeper into the skin? I would like to use this with your serums. Thanks

    • drgeorge says:

      We love ProCell products (our skincare company produces them under a private label agreement.) ProCell Therapies is a very class act and we think very highly of their entire team. Their microneedling product contains physiologic bio-signals that are pro-healing and anti-inflammatory. We have seen amazing improvements in aging skin and resolution of acne scars when microneedling, using their Microchannel Delivery Serum is combined with the Cellular Renewal Serum and Healing Accelerator.

  62. Barb says:

    Hi. Is it safe and beneficial to use AnteAGE products while also using an LED red light therapy device on the face? I also just started microneedling- at 63 I need help! I’ve already ordered my AnteAGE products.
    Thanks

    • drgeorge says:

      Red light has proved beneficial to skin in certain settings. The articles below deal with its proven usefulness in promoting wound healing and interfering positively with UVA-induced photoaging of fibroblast cells.

      There is no cause for concern when combined with topical use of the AnteAGE products. If anything, one would expect synergistic benefits. Let us know how it goes.

      Photodermatol Photoimmunol Photomed. 2017 Jan;33(1):4-13. doi: 10.1111/phpp.12282.
      Noninvasive red and near-infrared wavelength-induced photobiomodulation: promoting impaired cutaneous wound healing.

      Photochem Photobiol. 2014 Nov-Dec;90(6):1349-58. doi: 10.1111/php.12316. Epub 2014 Aug 18.
      Red light interferes in UVA-induced photoaging of human skin fibroblast cells.

  63. chila says:

    Hello,

    I was wondering if pure 2% hyaluronic acid + B5 was safe to use for skin needling for gliding purposes. Also, how can you find out what size molecules the HA you are using are?

    Thank You.

    • drgeorge says:

      Hi, Chila. By “gliding” I take you to mean using the product during microneedling to provide lubrication of the skin. If so, the most important thing to consider, based upon our mantra of using only physiologic substances on skin with a compromised barrier, is knowing what other ingredients are in the product besides HA and B5. The reactions we have seen, and ones reported in the literature, included vitamin C serums and HA products. Since the risk of a reaction is unknown until you actually try a product, I would do internet searches about the various ingredients to see what problems people have encountered, and then perhaps consider testing on a inconspicuous skin area somewhere other than your face. Caution is key.

      Just looked up the ingredients in the product: Aqua (Water), Sodium Hyaluronate, Sodium Hyaluronate Crosspolymer, Panthenol, Ahnfeltia Concinna Extract, Glycerin, Pentylene Glycol, Propanediol, Polyacrylate Crosspolymer-6, PPG-26-Buteth-26, PEG-40 Hydrogenated Castor Oil, Trisodium Ethylenediamine Disuccinate, Citric Acid, Ethoxydiglycol, Caprylyl Glycol, Hexylene Glycol, Ethylhexylglycerin, Phenoxyethanol, Chlorphenesin.

      I cannot recommend using this product IF you are microneedling – asking for trouble. Sometimes that kind of trouble turns out to be sizable and permanent.

  64. Janete says:

    Hello Drs, I would appreciate any advice, I am in my 70’s and had 3 professional microneedling treatments from January to April this year. The old acne scars/wrinkles/ marionette lines appear to be little improved ( photos were taken) although the surrounding skin is improved somewhat. I am due to have 3 more treatments this time with PRP which is more expensive and am wondering if the results are likely to be the same. In other words would it be better to go for fillers instead albeit they are very temporary.

    • drgeorge says:

      Hello, Janete. We are great fans of microneedling and have seen some pretty stellar results in improvements in texture, scars, and pigmentation. It’s an amazingly effective modality yet safe IF you are careful about what you apply to the skin for the first few hours following treatment. (Read the reply just below this.) Crows feet, smile and frown lines, and other creases can be improved but require multiple treatments. Deep lines can improve but fillers definitely have a place in managing that issue since the underlying tissue changes are deep. Now to PRP.

      Microneedling with PRP (platelet rich plasma) was trademarked as the “vampire facial” and popularized widely when Kim Kardashian had it done on her TV show. Many practitioners offer PRP microneedling, which involves drawing blood, centrifuging it, taking the platelet layer and then activating them so they release the growth factors and cytokines contained within their alpha granules, which is where PRP’s effectiveness comes from. (You’re right, it is quite expensive and certainly not for everyone, especially those squeamish about blood and needles.) We think there is a better way.

      A little history: In the early 2000’s, the use of PRP extended into orthopedics to boost healing in bone grafts and fractures. Continued success encouraged its use in sports medicine for connective tissue repair. The first human study published by Mishra and Pavelko, associated with Stanford University, supported the use of PRP for chronic elbow tendinosis in 2006. This study reported a 60% improvement immediately, 81% at 6 months and 93% decrease in pain at the final two year follow up. Aesthetic physicians jumped on the band wagon a few years ago. For injuries where a little boost in inflammatory response to improve vascularity and increase oxygen delivery is good, PRP plays a positive role.

      If you follow BFT, you know that when it comes to anti-aging and facial aesthetics, our opinion is inflammation is not desirable. In fact, it is something to be avoided whenever possible. That’s why we are not fans of products containing pro-inflammatory ingredients such as fat stem cell conditioned media. Applying products on a daily basis that promote inflammation is not anti-aging, it’s the opposite. PRP contains high concentrations of the very highly pro-inflammatory bio-signals TNF-alpha, IL-1 beta, IL-6, IL-10, and TGF-beta1, along with several other bio-signals that are beneficial such as PDGF and VEGF. The effect, then of applying PRP during microneedling is to exacerbate inflammation. Remember, inflammation when accentuated, persistent, or chronic, is what leads to fibrosis (scarring) and excess pigmentation in susceptible individuals. As you can see, we’re not fans of PRP although we do know it is popular (remember, the physician gets paid handsomely for using it.)

      So, what to do? (Beware, horn tooting time!) Several years ago we developed a family of microneedling solutions (AnteAGE MD, AnteAGE, and AnteAGE HOME) that are used exactly how PRP is used, at the time of and immediately after microneedling. Our products are based on our old friend, bone marrow mesenchymal stem cell conditioned media and hyaluronic acid. The MD version has additional TGF-beta3 (strongly anti-inflammatory). The concentration of condition media is highest in the MD product, then aesthetician, then home versions. All are effective in quenching the inflammatory response and promoting healing. Hundreds of thousands of treatments have utilized these products without report of an adverse event.

      Long winded answer but we hope it helps.

  65. Bailey says:

    Hi,

    Does your suggestion to use only physiologic ingredients apply to shallow (.25) micro needling — what’s referred to as “cosmetic”? Or are you mainly referring to deeper — .5 and above? If you mean ALL needling, then how soon after a .25 derma rolling session would it be okay to apply non-physiologic ingredients? thank you!

    • drgeorge says:

      Good question and one that brings up the major differences between “shallow” microneedling (0.3 mm or less) and “deeper” (0.5 mm or more.) As a starting point, state regulators across the country make a distinction between shallow and deeper microneedling because the trauma with longer needles is greater, there is often bleeding confirming “live” tissue is being injured, and the risks of infection (very unlikely due to the high vascularity of the face and scalp) are greater than shallow injuries. Estheticians, permanent make up and tatoo artists can do shallow microneedling in all but the most restrictive states (like California where I live.) Anyone licensed to give injections (nurses, some LVNs, and MDs) can perform “medical” or deeper microneedling.

      Obviously, anytime there is injury of living tissue, one must be careful what to apply to the skin since the normal barrier function is dramatically reduced or, if injury is extensive, non-existent. This period of vulnerability lasts while the micro perforations are patent, a period of several hours (although the range in published studies varies from a couple hours to many hours, depending our what you read.) For that reason, we caution that one not apply non-physiologic substances during this period of vulnerability. Shallow needling also decreases barrier function but to a lesser degree, How much less? We are not aware of solid evidence as to what period of time so advise caution. Certainly, a few hours later should be sufficient. If in doubt, one can always so a “test” patch on an area of the skin not on the face. The inner forearm is a good place, highly visible and quite thin. If you have no issues, there with a topical, you can consider a test area of the face. If no problem, you’re probably home free but no guarantees can be made.

  66. Bailey says:

    Hi,
    I’m wondering if your suggestion to only use physiologic ingredients pertains when doing shallow needling, what’s referred to as cosmetic needling of less than .5 mm? And if your suggestion applies to cosmetic needling too, at what point would it be safe to apply serums? Thank you.

    • drgeorge says:

      Needling at “cosmetic” depths, which in this instance we consider 0.3 mm or less (much of this based on regulatory edicts among the many states that allow estheticians to needle) is sufficient to reduce barrier function significantly. For that reason alone, one must be cautious as to what is applied to the skin. Allergic reactions to foreign substances can develop, perhaps only in sensitive individuals. 0.5 mm needles can elicit pinpoint bleeding meaning that live tissue has been injured. The risk for deeper needling is likely greater, but that does not mean shallower needling may not carry risks.

      If one wants to be cautious in using a new “serum” or other skin product on shallow needled skin, a safe way to test might be to use an area of skin not on the face or neck. The inner arm or inner thigh would be suitable places – out of sight and with relatively thin skin compared to other areas.

  67. lorraine says:

    Is it possible to not use anything at all directly afterward to avoid these issues altogether? Perhaps needling early in the day (at home) and not applying anything until evening or the next day?
    Also, what would your opinion be of stamping deep wrinkles with a 1mm 12 needle stamp and rolling (remainder) with a 1mm roller monthly at home?

    • drgeorge says:

      Certainly, it is not imperative that something be applied to the skin after microneedling. The benefits of shallow (0.3 mm) needling are trauma is minimal (hence a minor or minimal healing response) but penetration of topically applied products is significantly increased for a brief period of time post treatment. For that reason, we created the HOME and PRO (esthetician) versions of our AnteAGE Microneedling Solution. Deeper needling, which is only permitted to be performed by “medical” personnel (RNs, MDs) creates more trauma, hence a stronger healing response which can be nicely augmented when the right type of topical bio-signals are applied. Cytokines and growth factors, produced by cell culture or synthetic means. When one is attacking issues like deep lines, scars, stretch marks, pigmentation, etc., deeper needling in needed.

  68. Lisa says:

    Would applying a moisturizer (avene cicalfate) after 50 hours post needling have a deleterious effect? I had microneedling at 1mm depth nearly 3 days ago and my redness has still not resolved. The esthetician applied the Procell formula and I used HA for 2 days, but I still have the road rash look on several patches. Last year at .5mm, it resolved in 2 days with the same protocol-procell, HA, then cicalfate. I have found cicalfate to be very soothing in the past, but now worry it’s contributing to the agitation. How long after a 1mm microneedling does one need to worry about introducing irritants to the lower epidermis and should I worry about the length of the redness? (About 65 hours now).

    • drjohn says:

      avene cicalfate: Avene Thermal Spring Water (avene Aqua), Caprylic/capric Triglyceride, Mineral Oil (paraffinum Liquidum), Glycerin, Hydrogenated Vegetable Oil, Zinc Oxide, Propylene Glycol, Polyglyceryl-2 Sesquiisostearat, Peg-22/dodecyl Glycol Copolymer, Aluminum Sucrose Octasulphate, Aluminum Stearate, Beeswax (cera Alba), Copper Sulphate, Magnesium Stearate, Magnesium Sulphate, Microcrystalline Wax (cera Microcristallina), Zinc Sulphate.

      Yes, I would worry. Micronized metals like copper and zinc sulfate have know skin irritant properties, and microneedling makes you more susceptible to these kinds of immune problems. Lots of petroleum by products as well. Thermal spring water? Avene, do you want us to believe that that is good? prove it, please!

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